Objective To investigate the prevalence and main genotypes of carbapenemases in carbepenem‐resistant Enterobacteriaceae (CRE) .Methods A total of 114 strains of CRE were isolated in Shanghai Ruijin Hospital from May 2011 to June 2013 .The diameter of inhibition zone of imipemen or meropenem for these strains was not larger than 22 mm .PCR method was used to screen for the main carbapenemase genes (blaKPC ,blaIMP ,blaVIM ,blaOXA‐48 and blaNDM ) with previously described primers followed by nucleotide sequencing analysis . Conjugation experiments were performed to examine the transferability of plasmids .Pulsed‐field gel electrophoresis (PFGE) was used to show the relatedness of KPC‐2‐producing Enterobacteriaceae .Results Most of the 114 isolates were K lebsiella pneumoniae and Escherichia coli .Of the 114 isolates ,98 was positive for carbapenemases ,specifically ,78 blaKPC‐2‐positive ,15 blaIMP‐4‐positive ,2 blaIMP‐8‐positive ,1 positive for both blaKPC‐2 and blaIMP‐4 and 4 blaNDM‐1‐positive .None of the strains was positive for blaOXA‐48 or blaVIM .About 21 .4% (21/98) of the isolates were conjugated successfully .The 49 blaKPC‐2‐positive K .pneumoniae isolates were grouped into 12 types according to PFGE patterns .Majority (34/49) of these isolates belonged to the same type A .Conclusions BlaKPC‐2 was the primary epidemic genotype of Enterobacteriaceae in Ruijin Hospital ,followed by blaIMP‐4 .NDM‐1 carbapenemase was produced in 4 strains of CRE . Meanwhile , clonal spread of KPC‐2‐producing K . pneumoniae was observed in some departments of our hospital , such as surgical ICU , respiratory medicine and thoracic surgery . Appropriate measures should be taken timely and effectively to prevent the in‐hospital spread of resistant genes .

Objective To explore the value of early arterial blood lactate clearance rate and central venous oxygen saturation (ScvO2 ) monitoring in patients with severe pneumonia .Methods A total of 56 patients with severe pneumonia treated during the period from January 2012 to December 2013 were reviewed retrospectively .The arterial blood lactate concentration and ScvO2 were determined immediately after admission to hospital and 6 hours after admission to calculate the 6‐hour lactate clearance rate .APACHE II score was evaluated at the same time .The patients were divided into three groups according to APACHE II score:10 to ＜20 (group A) ,20 to ＜30 (group B) ,≥30 (group C) .The three groups were compared in terms of early arterial blood lactate clearance rate and ScvO2 and estimate their association with the prognosis of patients .Results The initial arterial blood lactate concentration did not show significant difference between the three groups (P>0 .05) .The early lactate clearance rate and ScvO2 at 6 hours in group C were significantly lower than in group B .The values in group B were significantly lower than in group A (P＜0 .05) .The mortality rate in group C was significantly higher than in group B ,and the mortality rate in group B was significantly higher than in group A (P＜0 .05) .The APACHE II score of the dead patients was higher than that of the suevivors ,but early lactate clearance rate and ScvO2 level were lower than those of the survivors (P＜0 .05) .APACHE II score was negatively correlated to early lactate clearance rate (r=0 .661 ,P＜0 .01) and early ScvO2 level (r=0 .579 , P＜ 0 .01) .Conclusions Early lactate clearance rate and ScvO2 level are good indicators to reflect the severity of disease and predict the outcome in the patients with severe pneumonia .

Objective To analyze the clinical features of subacute thyroiditis (SAT ) manifested as fever of unknown origin (FUO) for early diagnosis .Methods The clinical and laboratory data were retrospectively reviewed for 20 SAT patients manifected as fever of unknown origin from October 2009 to February 2013 .Results A total of 20 patients were finally diagnosed as subacute thyroiditis ,about 3% of the 661 FUO patients .Only 5 SAT patients had complained of angina or pain in the anterior region of neck .Thyroid enlargement and tenderness were observed in 14 SAT cases .Elevated serum thyroid hormone and a very low serum level of thyroid stimulating hormone were seen in 17 patients with SAT .Ultrasound scan of thyroid showed inhomogenous hypoechongenic texture in 14 patients .99m Tc pertechnetate scan of thyroid showed extremely low radiopharmaceutical uptake in all the 20 cases .All patients had received antibiotic treatment prior to admission .Conclusions Subacute thyroiditis is an uncommon but important cause of FUO .Detailed history ,physical examination and laboratory evaluation can help minimize the chance of misdiagnosis and unnecessary antibiotic therapy .

Objective To compare the efficacy and safety of levofloxacin 750 mg for 5 days versus 500 mg for 7‐14 days intravenous (IV ) infusion in the treatment of community‐acquired pneumonia (CAP ) . Methods This study was a multi‐center , randomized , open‐label , non‐inferiority , controlled clinical trial .The CAP patients were randomized to receive levofloxacin 750 mg IV daily for 5 days or levofloxacin 500 mg IV daily for 7‐14 days .The clinical symptoms , laboratory tests , imaging results and microbiology data were collected and compared between the two treatment groups in terms of efficacy and safety .Results A total of 241 patients were enrolled in this clinical trial from 10 study centers .Among these patients ,223 were eligible for full analysis set (FAS) analysis ,including 111 in 750 mg group and 112 in 500 mg group .Of the 223 patients in FAS ,211 were eligible for per‐protocol set (PPS) analysis ,including 107 in 750 mg group and 104 in 500 mg group .Two hundred and forty‐one patients were included in safety set (SS) ,including 121 patients in 750 mg group and 120 in 500 mg group .The median treatment duration was 5 .0 days in 750 mg and 9 .0 days in 500 mg group .The median total dose was 3 750 mg in 750 mg group and 4 500 mg in 500 mg group .The overall efficacy rate was 86 .2% in 750 mg group and 84 .7% in 500 mg group in terms of FAS at visit 4 ,which suggested that the efficacy of 750 mg group was non‐inferior to 500 mg group .Of the 111 FAS patients in 750 mg group ,40 were bacteriological evaluable ,and 41 strains of pathogens were isolated .Forty‐nine of the 112 FAS patients in 500 mg group were bacteriological evaluable ,and 51 bacterial strains were obtained .The bacterial eradication rate was 100% in both groups .The clinical treatment efficacy rate for atypical pathogens was 100% in both groups .In 750 mg group ,the most common clinical adverse drug reactions (ADRs) were injection site adverse reactions including injection site pruritus ,pain and hyperemia .The other common ADRs were insomnia ,nausea ,skin rash .The most common drug‐related laboratory abnormalities were neutrophil percentage decreased , decreased white blood cell (WBC ) count , alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation .Most of the ADRs were mild in severity and well‐tolerated .The safety profile of the two treatments was comparable in terms of the drug‐related treatment discontinuation and the incidence of ADRs .Conclusions The short‐course regimen of levofloxacin 750 mg IV for 5 days is at least as effective and well tolerated as the long‐course regimen of 500 mg IV for 7‐14 days in treatment of CAP .

Objective To analyze the drug resistance of Mycobacterium tuberculosis (MT) in elderly patients with recurrent pulmonary tuberculosis .Methods We collected 1 860 M T strains from elderly patients with recurrent pulmonary tuberculosis in our hospital from January 2005 to December 2013 to review the drug resistance profile of these strains .Another 300 patients with naive pulmonary tuberculosis were included as control group .Results Significant difference was found between the males and females in terms of the resistance rate to streptomycin ,rifampicin ,ethambutol ,amikacin ,capreomycin ,or ofloxacin (P＜0 .05) .Multi‐drug resistant tuberculosis (MDR‐TB) was identified in 24 .0% (357/1 489) and extensively drug‐resistant tuberculosis (XDR‐TB) in 9 .8% (146/1 489) in male patients ,which were significantly lower than the corresponding rates of 34 .2% (127/371) and 19 .7% (73/371) in the female patients (P＜0 .05) .In all the 1 860 patients with recurrent pulmonary tuberculosis , MDR‐TB and XDR‐TB accounted for 26 .0% and 11 .8% , respectively , significantly higher than the corresponding rates of 11 .3% (34/300) and 7 .0% (21/300) in the control patients with naive pulmonary tuberculosis .Single drug resistance was identified in 20 .0% (372/1 860) of the patients with recurrent tuberculosis and 41 .0% (123/300) of the control patients (P＜0 .05) .Conclusions The MT strains isolated from elderly patients with recurrent pulmonary tuberculosis show higher resistance rate ,especially in females .It is necessary to strengthen the monitoring of drug resistance in old patients with recurrent pulmonary tuberculosis .

Objective To understand the serotype distribution ,prevalence and antimicrobial susceptibility of Salmonella strains isolatd from diarrhea patients in Dongguan ,Guangdong Province .These data may be useful for disease control and prevention and clinical treatment .Methods From April to December in 2013 ,we collected 1 150 stool specimens from diarrhea patients . Salmonella strains were cultured by using Salmonella selenite brilliant green sulfa enrichment broth and selective chromogenic plates .Antimicrobial susceptibility was tested by ATB microbial identification and drug susceptibility system .Results A total of 72 strains of Salmonella were identified including 21 serotypes .The detection rate was 6 .3% (72/1 150) .Most of the strains were Salmonellatyphimurium (22/72 ,30 .5% )and Salmonellaenteritis (16/72 ,22 .2% ).Forty‐two (58 .3% )of the strains were isolated from the patients under one year of age ,12 (16 .7% ) strains from the patients of 3‐10 years of age ,and 18 (25 .0% ) strains from the patients of at least 20 years old .The results of antimicrobial susceptibility testing showed that 50 .0% of the strains were resistant to piperacillin and 48 .6% resistant to ticarcillin .Conclusions The prevalence of Salmonella typhimurium is the highest in local Salmonella‐associated diarrhea patients ,followed by Salmonella enteritis .Most of the Salmonella diarrhea occurred in the patients under one year of age .Clinicians should strengthen the monitoring of Salmonella in patients with diarrhea , especially in infants and young children , for early detection and treatment so as to reduce complications .

Objective To analyze the relationship between plasma concentration and efficacy , adverse drug reactions by monitoring vancomycin serum concentrations for appropriately treating the infections caused by methicillin‐resistant Staphylococcus aureus or other gram‐positive cocci .Methods Vancomycin concentration was monitored in the patients with indications for vancomycin therapy .Blood sample was taken after vancomycin was administered for at least 4 doses .The blood sample collected within 30 minutes before dosing was used to determine the trough blood concentration .The samples were taken within 30 minutes to 1 hour after infusion of vancomycin were used to estimate the peak concentration by fluorescence polarization immunoassay .The clinical data were collected at the same time to analyze clinical efficacy and safety .Results Vancomycin trough concentration ranged from 3 .22 mg/L to 50 .79 mg/L in 25 patients ,specifically ,＜ 5 mg/L in 3 cases ,5‐＜10 mg/L in 11 cases ,10‐15 mg/L in 3 cases ,and > 15 mg/L in 8 csaes .Peak concentration ranged from 13 .57 mg/L to 60 .47 mg/L ,specifically ,＜ 25 mg/L in 14 cases ,25‐40 mg/L in 7 cases ,and > 40 mg/L in 4 cases .The infection was cured in 80 .0% (20/25) of the patients .The gram‐positive cocci were eradicated in 87 .5% (21/24) of the patients .The dosage of vancomycin was adjusted in 13 patients according to the results of blood concentration monitoring .Majority of these patients (12/13 ,92 .3% ) were cured .Renal impairment was observed in 4 patients .Conclusions Vancomycin is safe and effective in treatment of methicillin‐resistant Staphylococcus aureus and other gram‐positive bacterial infections . Vacomycin concentration varies from person to person . Serum concentration monitoring is required to achieve best outcomes and the goal of individualized treatment of vancomycin.

Objective To explore the characteristics of pathogenic bacteria and risk factors for stroke‐associated pneumonia (SAP) in senile patients in order to privide basis for early clinical intervention .Methods A retrospective study was carried out to review the clinical data of 689 SAP patients treated at a university hospital between January 1 ,2011 and December 12 ,2013 . The pathogens from sputum and their antibiotic resistance profiles were analyzed .Multivariate Logistic regression model was used to screen relevant factors for stroke‐associated pneumonia (SAP) in a case‐control analysis at 1∶1 ratio .Results Of the 684 bacterial strains isolated from sputum , 545 (79 .7% ) were gram‐negative bacteria . The top bacterial species were Pseudomonasaeruginosa,Klebsiellapneumoniae,Acinetobacterbaumannii,and Enterobacterspp.Gram‐negativebacteria were highly resistant to most of the antimicrobial agents . About 31 .8% of the Acinetobacter strains were resistant to imipenem .A total of 139 (20 .3% ) gram‐positive strains were isolated . Staphylococcus aureus was the most frequently isolated gram‐positive pathogen (51 .8% ) , of which 63 .9% were resistant to methicillin (MRSA) .Most gram‐positive bacteria were sensitive to vancomycin , teicoplanin and linezolid . Multivariate Logistic regression suggested that age ( OR = 5 .632 ) , NIH stroke scale (NIHSS) score (OR= 4 .126) ,dysphagia (OR= 3 .481) , totally bedridden (OR=3 .431) ,mechanical ventilation (OR=4 .214) ,hyperglycemia (OR=2 .076) ,hypoalbuminemia (OR=2 .008) ,and high serum cortisol (OR=1 .825) were the major risk factors for SAP in senile patients .Conclusions Multiple antibiotic‐resistant pathogens are usually identified in the senile SAP patients .Early intervention to control the risk factors of SAP is important for prevention of SAP in senile patients .

Objective To evaluate the utility of CD4+ TCR tetramers‐based flow cytometric analysis and cell climbing slice assay in detecting antigen‐specific CD14+ monocytes in the blood of tuberculosis (TB) patients .Methods CD4+ TCR tetramers were used to detect tetramer‐positive CD14+ monocytes in the peripheral blood (PBL ) samples of inpatients with advanced pulmonary TB (PTB) by flow cytometric analysis .The PBL samples obtained from non‐TB patients and umbilical cords were used as controls .These tetramers were also used to examine tetramer‐bound CD14+ monocytes and Mycobacterium tuberculosis (MTB) antigen‐specific and tetramer‐bound cells by cell climbing slice in situ staining .Results The median percentage of tetramer‐bound CD14+ monocytes in PBL samples from PTB patients ,non‐TB patients and umbilical cords were 1 .32% , 0 .50% and 0 .26% respectively by using CD4+ Vα21‐J39/Vβ29‐D1‐J2 tetramer , while the medians were 1 .05% , 0 .49% and 0 .19% respectively by using CD4+ Vα21‐J39/Vβ29‐D2‐J2 tetramer . The percentage of tetramer‐bound CD14+ monocytes in PTB patients group was significantly higher than the other two control groups .In cell climbing slice in situ staining ,tetramer‐bound CD14+ monocytes ,and MTB antigen‐specific and tetramer‐bound cells were positive in PTB tissue compared with negative in control tissues . Conclusions CD4+ TCR tetramers‐based flow cytometric analysis and cell climbing slice assay could be used to sensitively detect M TB antigen‐specific CD14+ monocytes in the blood of TB patients ,and more accurately evaluate the changing profile and clinical significance of these cells in TB patients .

Objective To investigate the distribution and resistant pattern of Enterobacter cloacae to antimicrobial agents for reasonable use of antibiotics .Methods E .cloacae strains were isolated from patients from January 2009 to December 2013 .The strains were identified by VITEK‐2 Compact System of BioMerieux and tested for antimicrobial susceptibility by Kirby‐Bauer disk diffusion method .The results were analyzed .Results A total of 397 nonduplicate E .cloacae strains were isolated during 5 years ,accounting for 5 % of the total gram‐negative isolates . The strains were mainly isolated from sputum (48 .9% ) , followed by secretions (30 .5% )and urine (7 .3% ) .The percentage of E .cloacae strains resistant to all the antibiotics tested was on decline except carbapenems ,cefoxitin and amoxicillin‐clavulanic acid .Carbapenems were relatively more active against E .cloacae strains .The E .cloacae strains showed higher resistance rate toβ‐lactams .Conclusions It is necessary to strengthen the monitoring of clinical isolates to guide rational use of antimicrobial agents .